Ronny Morgan could hear
voices no one else did. The late-night hosts on television,
Jay Leno and David Letterman, had personal messages for him,
and in the days before his parents committed the 18-year-old
former high school baseball star to a Palm Beach clinic, he
would sometimes bring his face near the television set, his
eyes darting wildly, to better understand what they were
telling him. Everyone, perhaps even Ronny himself, knew he was
unraveling. Always rather hyper, by early May, while staying
with his mother in Boca Raton, he went into a frenzied state
of agitation, playing his gangsta rap tapes extra loud,
jabbering at all hours, menacing his uncle Joe, who lived with
them. In his notebook of rap poems, he wrote, "I’m afraid I’m
getting schizophrenic."

He was right, as it turned out,
but he never got the help he needed. On May 25, less than two
weeks after he was released by South County Mental Health
Center in Delray Beach following a mandatory psychiatric exam
— and against the recommendations of two psychiatrists there —
he beat his father to death with a red baseball bat while his
dad watched TV at his home in Pembroke Pines. The day before
the killing, he later told police, he had what he felt was a
divinely inspired dream: "My father was gonna go to heaven" —
if he would only hit him with a baseball bat.

The killing was one of a series
of recent preventable tragedies — suicides, stabbings or
shootings of the mentally ill by cops — highlighting a mental
health system that is essentially in shambles in South
Florida. The state and federal governments fund $58 million
worth of adult community mental health services in the four
South Florida counties, according to the Department of
Children and Families (DCF), but neither patients nor
taxpayers are getting much for it. Faced with everything from
a stark shortage of crisis beds to relatively low-paid and
ill-trained staff, community clinics are, critics say, too
often kicking out still-deranged people to the streets or
their unprepared families with no effective followup care.
Even with much-touted reforms in some counties in recent
years, including Broward’s Mental Health Court and assorted
outreach teams, the most seriously mentally ill are still
largely enmeshed in a revolving-door approach that keeps them
bouncing between clinics and the streets and jails. As a
result, says Miami-Dade County Court Judge Steven Leifman,
"Our jail has become the public psychiatric hospital for our
community." In Miami-Dade, Leifman notes, as many as 20 to 30
percent of the jail population have treated or untreated
mental illness, with 500 people a day on psychotropic
medication.

Too poor or disoriented to
navigate a patchwork of limited services, the severely
disturbed generally don’t get treatment or vital medicines
until they endanger themselves or others. When they’re on
medication, people with paranoia or psychosis are no more
violent than others. But left untreated, they often end up in
jail or, as happened five times in the past 18 months in Miami
alone, they’re gunned down by policemen. And once in jail, the
mentally ill usually encounter second-rate care, no care at
all or, some Palm Beach County families charge, outright
brutality; as a result, they can deteriorate further into
madness, posing greater risks to guards and, later, to
themselves and the public once they’re released.

The saddest part of it all is
that these fiascoes don’t have to happen. With the latest
medicines, long-term, well-managed outpatient treatment, and
housing assistance, most of the severely mentally ill —
including those with schizophrenia — could lead functional,
even productive, lives. But they’re not getting anything like
that, and thanks to shortsighted efforts to keep down
spending, we’re all paying the cost in what one advocacy
group, the Florida Council of Behavioral Healthcare, calls
"human tragedy and a waste of taxpayers’ money." Of course,
there doubtless are some dedicated professionals doing their
best to help this hard-to-treat population. But as Judge
Ginger Lerner-Wren, the presiding judge of the Broward County
Mental Health Court, says, "Communities are literally in
crisis because public mental health care has never been
developed to any effective capacity and is woefully
underfunded."

For Rosemarie Morgan, the
failures of Palm Beach County’s mental health system have
struck home with the death of her ex-husband and a son facing
trial for murder once he’s deemed competent to stand trial. "I
want to get him proper medication, and a good doctor who deals
with mental illness," she still hopes, but that reasonable
goal eludes most families in Palm Beach County grappling with
serious mental illness, according to local leaders of the
family-based advocacy organization the National Alliance for
the Mentally Ill (NAMI). "Mental health care in Palm Beach
County is such a joke," says Ellie Sikiossy, the president of
the local chapter.

As for Rosemarie’s son, Ronny,
although he’s been receiving a relatively cheap, outdated
anti-psychotic medication, Haldol, since mid-May in the North
Broward jail, he’s still almost as delusional as ever. That
was amply displayed at his Sept. 7 hearing before Broward
Circuit Court Judge Susan Lebow. Wearing an open-necked green
jail outfit, the short-haired youth, his left wrist still
bandaged from a suicidal attempt to bite himself, sat quietly
at first as three psychologists testified that he was
genuinely mentally ill and not competent to stand trial. The
defense’s expert psychologist, Dr. Phil Heller, pointed out
that Morgan was "schizophrenic and extremely delusional,"
banging his head against the wall, still hearing messages from
the TV and insisting on conducting his own defense. Even so,
the prosecutor attempted to portray those and other symptoms
as still permitting Morgan to be tried.

But when Ronny Morgan spoke up on
his own behalf, all the efforts to discredit the psychologists
were shown to be as much of a sham as the so-called
"treatment" he’s received in jail. Grasping an astrology book,
Love Signs, that his mother gave him, he turned in the witness
stand to face Judge Lebow, seeking to make her understand him.
"Do you believe in astrology?" he asked Lebow, then read aloud
from the book: "Pisces vibrates the number seven." He
continued, "And that’s my birth date. Also, my job here on
Earth was to take care of the lost souls, but I got confused
with the music and the TV." His mother stood up to reassure
him as he went on, "I’m guilty of my crime. I’m shaking right
now. I’m scared. I just don’t want to go to hell."

The judge agreed with the defense
attorney, Robert Udell, that Morgan wasn’t ready to stand
trial and ordered that he be sent to a secure psychiatric
hospital for treatment. The wait for a hospital bed could be
as long as six weeks. "He’s going to get good treatment now,"
his mother said later. But if he does become competent to
stand trial, Udell said he would offer an insanity defense. He
also plans to sue South County Mental Health Center for what
he and Morgan’s mother say was an inappropriately early
discharge. "He was clearly psychotic at the time they released
him," Udell contends. "He needed treatment, but they kicked
him out."

His mother has tried to find
decent treatment for Ronny as she watched her son deteriorate
over the years. His grades tumbled, he couldn’t stay on the
baseball team, he started smoking lots of pot, and by the 10th
grade, he dropped out. He visited, briefly, a few therapists,
and one psychiatrist he saw told her he was depressed, but the
anti-depressant he received didn’t halt his downward slide,
and he soon stopped taking it at all. For a while, he managed
to pull himself together enough to complete his GED and hold
down a job as a bag boy at Publix, but by May all that had
started to crumble.

Rosemarie Morgan, a former
psychiatric aide, knew her son should be detained under the
Baker Act, which allows someone to get an involuntary
psychiatric exam at a "crisis stabilization unit" if he’s
considered a danger to himself or others. Reluctant to call
the police and scared to bring him to a hospital herself, she
kept calling her ex-husband, Rick, to help bring Ronny to a
nearby community hospital. "I didn’t want to be upstairs with
Ronny myself," she recalls about the day he was committed.
When Rick Morgan finally arrived, they convinced their son to
go to the hospital, where the staff agreed he needed to be
committed and arranged for an evaluation at South County
Mental Health Center.

After three days there, he was
released, against the recommendations of two psychiatrists who
believed that he should be kept involuntarily. Dr. Womesh
Sahadeo, for instance, wrote that Morgan "posed a real and
present threat of potential harm," adding that he was refusing
medication and was "responding to internal stimuli, believing
that TV is talking about him." Another psychiatrist also noted
Ronny’s delusions about the TV, adding, "[He] burned both
upper arms with a cigar. Has no understanding of his need for
treatment." For reasons of patient confidentiality, South
County officials won’t explain why those findings were
overruled and Morgan was released.

Under the Baker Act, the mental
institution has up to 72 hours to determine if a patient is
still likely to be dangerous and petition a court for an
involuntary commitment order if clinically necessary.
Otherwise, to protect the civil liberties of patients, the
institution either can ask the patient to voluntarily commit
himself or release him. While at South County, Ronny didn’t
take any medication and became angry over being committed ("It
pissed me off," he later told police), fueling the homicidal
rage that exploded nearly two weeks later.

When Rosemarie visited her son at
the facility, he told her, "I’m holding on." She didn’t hear
anything about his progress from the clinic until she got a
call from a medical staffer telling her that Ronny was going
to be released. "Why are you releasing him when he needs
medication?" she asked.

"It’s the law," the staffer told
her.

"What do we do now?" she wondered
aloud, shocked and overwhelmed about the prospect of his early
release. He still seemed just as hyper, she remembers, and she
wasn’t told anything about how they should deal with him on
his release — although educating and involving families has
been proven to sharply reduce relapses. Ronny Morgan went to
live with his father in Pembroke Pines, in part because
Rosemarie couldn’t handle him by herself anymore.

Discharged without even a written
prescription or pills to tide him over, Ronny Morgan was given
only a fact sheet on bipolar, or manic-depressive, illness,
she says. He didn’t obtain a filled prescription for his
psychotropic medication until the next week, when his father
found a psychiatrist for his son out of an insurance booklet.
A few days after that first psychiatric visit, Ronny killed
his dad.

It can take at least six weeks,
if not more, for some psychiatric medications to have a
therapeutic effect. Successfully treating a patient with just
the right dosage and medicine can take months, with recovery
from a single psychotic episode requiring as long as two
years.

At that meeting with the
psychiatrist a few days before Ronny killed his father, he
threw near-miss punches at his dad right in front of the
doctor, Rosemarie Morgan says. But Rick Morgan still thought
he could control his son’s behavior. Every few days, she urged
Rick to bring his son back to the clinic, but he declined.
Neither parent had any real idea on how to handle his illness
on their own.

Before Ronny began fitfully using
his new anti-psychotic medication, Zyprexa, the vivid dreams
about killing his parents had already begun. On his first
night home, he told police, he had a dream about killing his
mother. He saw his face starting to do strange things in the
mirror, and soon, with all his family standing around, "I put
her on the ground, and I had my forearm across her throat, and
I could feel I was about to crush it, and I woke up." A little
over a week later, he had the dream about sending his father
to heaven with the baseball bat, following it up the next day
by, in fact, killing him, shortly after they played catch
together.

The last time Rosemarie spoke to
her ex-husband she asked him, "Are things going all
right?"

He reluctantly conceded that they
weren’t. "If anything’s going to happen, it should happen here
in this house," he told her.

"Don’t let anything bad happen,"
she answered. "We have to Baker Act him." He never got the
chance.

She got the call at work from her
brother and told him to call the police. Ronny had showed up
at her house, his clothes still bloodied, and told his uncle
and grandmother, who were shocked by it all, "I killed my
father." After washing up at their house and returning from
the convenience store with some cigarettes, he was arrested
and brought to the Boca Raton police station for
questioning.

Why did South County Mental
Health Center, a $15 million annual operation, release Ronny
Morgan so soon? Mental health officials contend that such
facilities have little choice given the requirements of the
Baker Act, but reformers and malpractice lawyers say other,
cost-saving factors may be at work. In the view of Jeff
Lefton, the associate director of South County, patients’
mental status can change during the days they’re being
evaluated, leading to cancellations of scheduled court
hearings, as in Ronny Morgan’s case. He adds, "If they no
longer meet [Baker Act] criteria, then we’ll discharge them —
unless they stay on as a voluntary client. It’s difficult:
Sometimes, they may not meet criteria, but still may need
mental health treatment."

"It’s not against the law to
think you’re Napoleon. It’s only a problem if you’re Napoleon
and you go to war. The dangerousness issue, that’s the real
problem," Laura Leonard, the adult mental health coordinator
for the Department of Children and Families in Palm Beach
County, told the Sun-Sentinel. Leonard’s agency gives about $5
million a year in state mental health funds to South County.
Unfortunately, she tells City Link, families often
misunderstand facilities’ obligations under the Baker Act:
"They don’t have the legal ability to hold someone if it
doesn’t rise to the level of imminent harm to themselves or
others. And I can understand how that can be problematic to
family members."

Still, a series of dubious
discharges and escapes in recent years have underscored
troubling questions about local institutions.

In late April, Fort Lauderdale
police brought a chronically homeless person, Chris "Cowboy"
Kyhl, to Broward General Hospital after he threatened to jump
off the City Parking Garage near the downtown library. They
talked him down and brought him to the hospital’s
psychological unit with the aim of "Baker Acting" him.
According to a police report, they met with a nurse and filled
her in on his history while an officer started filling out the
involuntary examination paperwork — before being told that the
medical staff would now handle it. Nine hours later, Kyhl was
released and shortly after, the intoxicated "Cowboy" climbed
on top of the garage, then had a change of heart while
dangling from a seventh-floor railing. A passerby tried to
save him, but Kyhl’s sweaty hand slipped and he plunged to his
death.

A spokeswoman for Broward General
Hospital, Sara Howley, says patient confidentiality bars her
from discussing the specifics of the case, but contends, "We
have good policies and procedures in place to handle these
situations." But at a meeting with hospital staff in June,
representatives of the police department’s homeless outreach
team and the Homeless Assistance Center met to voice their
concerns about the hospital’s discharge policies and to
improve communication among the various agencies. According to
the civilian member of the police team, R. Courtney, one
hospital administrator tried to explain that since Kyhl wasn’t
officially Baker Acted — the paperwork wasn’t completed by
police — they weren’t obliged to keep him. "That’s bullshit,"
Courtney recalls telling him. "He was brought to your psych
observation room in handcuffs."

The outreach team is now trying
to get the hospital staff to pay attention to the police
team’s background information on mentally ill individuals when
doing their Baker Act evaluations. (Howley insists that the
hospital welcomes information about patients from other city
agencies.) But Officer Scott Russell says of the hospital’s
discharge approach: "Obviously, there’s a cost problem." He
adds, "What happens is, if [the mentally ill] really want to
commit suicide, they know if they tell the doctor they’re OK,
the doctor will release them."

For Christopher Kane, his
determination to kill himself wasn’t even foiled when he was
kept for observation at South County. Depressed and suicidal,
he was admitted briefly to South County in mid-December, after
similar stays in previous months, then released by a
psychiatrist as no threat to himself or others. But right
afterward, on the evening of Dec. 18, Kane flagged down a Palm
Beach Sheriff’s officer and told him that he wanted to kill
himself. "Without further treatment," the officer wrote on his
involuntary exam form, "[patient] will apparently harm
himself." Kane was brought back to South County, where he
should have been kept under a careful suicide watch. Hospital
staffers told police that the next morning, after being
refused a cigarette when he awoke, he declined breakfast.
About 15 minutes later, the staff reported, they saw him
slumped over his bed; he died less than two hours later at the
Delray Medical Center from an overdose of drugs — including
OxyContin — that he’d smuggled into South County in a pill
bottle later found in his clothing.

The family’s attorney, Robert
Saylor, is preparing a lawsuit against South County, and says,
"There’s a reasonable case that there was negligence,"
particularly given the history of previous discharges.
Associate director Jeff Lefton won’t comment on the case for
legal and confidentiality reasons, but says of their suicide
prevention policy, "Patients change into a gown, and we go
through their belongings, but don’t do a cavity search. We
respect the individual’s dignity."

South County’s respect for
patient dignity, however, doesn’t always seem to include
helping prevent their deaths. Last November, a West Palm Beach
jury awarded more than $400,000 to the parents and estate of a
mentally ill man who was shot and killed by police hours after
jumping the fence at South County. Jair Salazar, 27, was
hearing voices and suffering from paranoid schizophrenia when
he checked himself into the center. On March 13, 1998, he
escaped, and although the center phoned his parents, the
center staff didn’t bother to chase him or call the police
because, they reasoned, since he’d voluntarily committed
himself, his departure wasn’t technically an escape. It was
typical of the bureaucratic thinking that afflicts area mental
health agencies.

Later that night, Salazar
wandered into a parking lot next to the Duncan Conference
Center, and police responded to complaints of a man
threatening people. He lunged at the officers with a socket
wrench and was shot by a policeman, who was later cleared of
any wrongdoing. During the trial, the center’s attorney
argued, "South County helped him the best they could, but he
ran from them."

Unfortunately, the clinics’ best
may not be good enough, particularly when there are shortages
of beds, or patients encounter indifferent or ill-trained
staff. South County, for instance, was cited by state
evaluators earlier this year for such flaws as lack of
training in both Baker Act procedures and crisis intervention
for several staff members, as well as a failure to show a
clear followup plan for half their patients. Jeff Lefton says
the 16 problem areas, out of 381 studied, mostly involved
inadequate documentation of their efforts and are being
rectified.

Poorly trained staff, though, can
cost lives. For example, in 1995, Brian Mullen, 21, went to
the 45th Street Mental Health Center in West Palm Beach after
being hospitalized for three days at a nearby hospital
following a suicide attempt with drugs. Referred by a
psychiatrist at the hospital, he went to 45th Street seeking
residential treatment for his depression, but an admissions
aide sent him away after a 15-minute meeting as "not
suicidal." Subsequently, he hanged himself at home, and
attorney Robert Saylor settled with the facility for a large
but undisclosed amount on behalf of Mullen’s family. The
current medical director, Dr. Suresh Rajpara, won’t comment on
an incident that preceded his tenure but says of their Baker
Act decisions: "We like to err on the safer side of more
monitoring."

Some institutions, however, have
a rather limited view of patient and public safety. Last
November, Kathryn Jamnicki, a woman with a long history of
mental illness who stabbed her mother to death 13 years
earlier, knifed a stranger in a Publix in Fort Lauderdale.
Three weeks before, the Sun-Sentinel reported, she’d been
released from a psychiatric hospital that the DCF won’t name.
Her attorney, Ryal Gaudiosi, said it was the ninth release in
nine years for Jamnicki. "There is very little in this county
for people who are mentally ill," Broward County Chief
Assistant Public Defender Howard Finkelstein said at the time
of the Publix stabbing.

Apparently, the hospital staff
assumed she was no longer a danger to herself or others or,
perhaps, they had simply run out of room. The number of
inpatient beds has been markedly shrinking since the
deinstitutionalization of state hospitals began in earnest in
the 1970s. By next April, state hospitals will have lost 3,600
noncriminal inpatient beds since 1979. But the number of
criminal beds has more than doubled to 890 since 1980. The
community clinics that were supposed to serve patients never
filled the gap with either inpatient beds or, in most cases,
effective outpatient care. Hence, the revolving door of Baker
Act patients cycling in and out of facilities.

Critics say institutions too
often narrowly interpret the Baker Act, by either refusing to
offer involuntary treatment or kicking out patients before
they’re ready. The apparent reason: to make room for other
patients or save on costs. One Broward County mother, for
example, recalls begging crisis workers from Henderson Mental
Health Center to arrange the Baker Acting of her son because
his house was in flames from unattended candles. By the time
they and the fire department had arrived, though, he was
sitting on his front lawn, the house still burning, calmly
playing his guitar. "They were standing there while I asked
them, ‘Please take him,’ " she says. They refused — on the
spurious grounds that he didn’t seem dangerous at that moment.
"It’s just a turnstile," she says of the system that’s seen
her son Baker Acted 60 times. (Steve Ronick, the CEO of
Henderson, said he wasn’t familiar with the alleged incident,
but asserts, "We have a track record of
responsiveness.")

The clinics, however, seem to
have a peculiarly high threshold for judging patient danger.
"If they don’t see blood on the floor, they’ll let him go,"
says Ronny Morgan’s attorney, Robert Udell, a view echoed by
Judge Leifman and other advocates for the mentally ill. "They
have to have a gun to their own head or someone else," Leifman
contends. But he says the law, which also does allow people to
be committed if they’re at risk of neglecting themselves,
should be applied more broadly to the mentally ill. At the
same time, reformers concede that institutions can be held
liable if they abuse the process to hold people improperly, as
a 1999 state Supreme Court panel reported occurred with the
elderly. Still, Leifman believes Florida should amend its law
to join the 41 other states that allow judges in civil cases
to order outpatient treatment, including medication, for those
who don’t recognize the need for treatment.

The facilities’ release of
patients who aren’t yet stabilized could be driven by
financial need, some observers contend. Dr. Sanford Kaufman, a
noted Palm Beach County psychiatrist, says, "There are some
institutions that dictate to the physicians how long to keep
people, although they’ll deny it." Indeed, Judge Leifman and
other mental health advocates say, the state’s own
reimbursement policy could be contributing to the problem,
because it provides a flat fee to the facilities regardless of
how many patients are served. As Angela Vickers, a
Jacksonville attorney and state NAMI board member, says,
"There’s no accountability: Providers get the same amount of
money raining in whether they serve 10 people or 1,000 people,
and whether they engage in malpractice or good practice."
(DCF’s Laura Leonard strongly disputes that view, contending
that the state engages in extensive quality monitoring, and
that the facilities’ payments are geared in part to the level
of staffing and inpatient beds.)

Whatever the cause of early
discharges, a reading of the statute itself shows that
virtually all facilities are using it to limit costly
involuntary commitments to only those who are, in Leonard’s
words, in "imminent harm." But the statute doesn’t even use
that term, referring instead to the "substantial likelihood" a
person will be dangerous in the "near future" based on "recent
behavior causing, attempting or threatening such harm." The
families of patients such as Ronny Morgan, Chris Kyhl and
Christopher Kane no doubt feel that the law was applied
improperly to them.

Clinic leaders resent the charge
that they’re kicking Baker Act patients out too soon just to
save money. "I don’t think anyone who is a practicing
psychiatrist is showing people the door [for financial
reasons]," says Jeff Lefton of South County. He adds that the
tragedies making headlines are quite rare and at least his
facility, with its 20 crisis beds, can’t be blamed: "We don’t
have any crystal balls. We look at an individual case and
assess clients the best we can. We have 300 Baker Acts a month
... Those [deaths] are things that happen."

Yet even when the mental health
system doesn’t leave its victims dead, patients and their
families face the daily wounds of fighting to get help for the
already devastating mental illnesses crippling them. In the
process of dealing with poor or negligent treatment — as well
as bureaucratic runarounds — families in South Florida watch
with horror as their loved ones continue to
disintegrate.

For Bobbie Norris of North Palm
Beach, the challenge often has been just to ensure that her
son survives both the clinics and jails he’s been placed in
since he started to crack up four years ago. Her son — we’ll
call him Andy — became isolated and disoriented about the time
he turned 20. First admitted to Palm Beach Gardens Hospital,
he attacked a nurse there and was Baker Acted to 45th Street,
where he vomited, choked and nearly overdosed on the excessive
amounts of psychoactive drugs given him, she alleges. "They
almost killed him at 45th Street," she says. He was
transferred to St. Mary’s ER, apparently for overdose
treatment, and then put back in 45th Street. Still
hallucinating, he soon was discharged when she went to court
seeking an independent medical exam of him, in part to assess
a painful lump on his neck the staff at 45th supposedly
ignored.

Over the years, although he’d
return to 45th Street, he rarely got much better. He used
drugs and alcohol, and was arrested a few times for DUI, drug
and even assault charges (once against his father). Last year,
when he was arrested for cocaine possession and threatening a
hotel employee with a baseball bat, he was locked up in the
Palm Beach County Jail for six months — and, his mother says,
denied both psychiatric medication and medical care he needed
for an ear infection. At one point, an administrator with EMSA
Correctional Care, the for-profit firm that provides jail
health services, allegedly inquired about her schizophrenic
son, "Are you sure he’s not faking it?" His parents couldn’t
afford bail while he was awaiting trial and court hearings on
his competency to stand trial.

Meanwhile, he lost at
least 40 pounds while in the jail and became more withdrawn
and frightened. His mother also says jail officials told her
that he was isolated from other prisoners several times for
unruly confrontations with guards. He doesn’t remember that,
but he says, "One time, I was lying in my bed, and they came
in to search my room and I couldn’t get out of bed. They
dragged me out of bed, beat me up, took my clothes off, and I
remember this one guy kicked me." On another occasion, he
claims, he was beaten up by guards when he stopped for a drink
at a water fountain before returning to his cell. The family
doesn’t have medical records or other evidence to back up his
allegations, however, and they say they haven’t filed lawsuits
against either 45th Street or the Palm Beach County Jail
because they can’t afford a lawyer.

In Andy’s case, his troubles
continued even after he was shipped in December to the North
Florida Evaluation and Treatment Center in Gainesville to get
him well enough to stand trial. When he was released this past
May, he was placed on a form of probation that allowed him to
avoid jail if he kept out of trouble for 18 months. But to do
that, his parents knew, he needed skilled drug counseling and
therapy, along with regular medication. He never got the help
he needed, despite entering a new state-funded program,
IMPACT, drawing on staff from both 45th Street and South
County, that was supposed to offer outpatient drug treatment,
"case management," at-home visits and a host of intensive
services for the most troubled patients: substance-abusing
mentally ill patients with repeated incarcerations. The
program’s central mission was to treat these hardcore "dually
diagnosed" patients, but even with a caseload of only 30
patients as of June (since expanded), Norris says, "He didn’t
get drug counseling or treatment."

At most, his parents say, he’s
received only superficial visits lasting about 10 minutes a
week to check on his medications. About two weeks ago, after
inquiries about the program by City Link, a social worker
actually spoke to him for 45 minutes. Ironically, Norris had
to fight hard to get her son in the program, overcoming
efforts by the supervising psychiatrist to discourage his
enrollment. Others never make it past the assorted runarounds
placed in their path. One woman, who has asked to remain
anonymous, clamored for weeks to enroll her son, but finally
couldn’t even get a preliminary appointment for him and gave
up. "It was a dead end," she says.

The program costs taxpayers $2.5
million, but it’s not clear what the public or patients are
actually receiving.

What is clear is that the results
of the treatment program have been a disaster for Andy. He
goes on and off his anti-psychotic medications, and, his
father says, his thinking has become disordered, his
appearance is deteriorating and his face often takes on a
hard, angry look. "There’s a storm going on inside his head,"
his father says. And last month, he was arrested yet again
after he got into a dispute with a nightclub bouncer and was
booked for trespassing and resisting arrest, thus violating
his probation and raising his risk of returning to jail. If
jailed, of course, he’ll doubtless deteriorate further,
increasing the chances that he’ll be arrested or Baker Acted
again after his release.

The IMPACT program was supposed
to prevent just such endless recycling through the mental
health and criminal justice systems. It’s based on a
NAMI-endorsed Assertive Community Treatment (ACT) model that’s
succeeded elsewhere in the country and found now in 22 teams
around the state. Each 12-person team comprises social
workers, nurses and a doctor to offer round-the-clock,
wide-ranging support. But local and state NAMI leaders,
including the president of the Florida state chapter, Faye
Barnette, believe that the Palm Beach County version has, so
far, failed to deliver on the promises it offered in its $2.5
million contract. "It’s not working very well," Barnette
says.

The local DCF evaluation in June
of the program found a variety of problems, noting, for
instance, that "substance abuse services are not being
addressed." In other words, the centerpiece of the entire
multimillion-dollar program didn’t seem to be offered. But
DCF’s Leonard insists that critique merely referred to the
program’s failure to properly document their drug services.
She says that after IMPACT worked out the program’s startup
"bugs" and high turnover rates, it is now finally providing
all the services the state — and taxpayers — are paying for.
"Knock on wood," she adds.

IMPACT leaders, though, don’t
seem very willing to explain how they’re applying their funds.
When City Link asked one of the IMPACT administrators at 45th
Street, Donna Harris, about Bobbie Norris’ struggle to get
drug treatment for her son, she said, "I don’t like where this
is headed" and ended the interview. Before then, Harris had
claimed, "Members are given extensive substance abuse
services," and that entry into the program is open to all who
qualify.

In Broward County, there appears
to be a similar contrast between the claims made for
innovative programs and what they actually offer some families
in need. For instance, Henderson boasts about its 5-year-old
mobile crisis team that’s supposed to be dispatched in a
mental health crisis, in part to avoid using the police. "We
triage in the order of lethality and danger, and we don’t slip
up," says Henderson CEO Ronick. But one mother, who asked not
to be identified to protect her son, says that even armed with
a written recommendation from a Henderson psychiatrist to
Baker Act her psychotic son, she couldn’t get the vaunted
mobile crisis team to show up at her house for about a week.
As the days passed, he became more unhinged, wallowing in
filth in his room and threatening his mother: "If you send me
anywhere, God will make you die." Eventually, after pleading
with both NAMI and the Henderson psychiatrist, some Henderson
staffers arranged for a short-term Baker Act evaluation before
he was released again from the clinic. "I don’t know what to
do," she complains. "I don’t want him to fall between the
cracks."

Perhaps the most striking
difference between the official description of services
provided and the reality comes at the Palm Beach County Jail.
"Mental health and medical treatment is given the highest
priority," says Diane Carhart, the spokeswoman for the Palm
Beach Sheriff’s Office, which administers the jail. The
sheriff’s office has paid since 1993 more than $45 million to
EMSA Correctional Care and its affiliated company, Prison
Health Services. What are inmates — and taxpayers — getting
for all this money? "Inmates staying in our facility receive
the best possible medical treatment. They receive the same
kind of medical care they would receive on the outside,"
Carhart says.

That’s not a view shared by the
inmates and families who have filed hundreds of lawsuits
against EMSA and Prison Health Services around the country.
There have been 15 lawsuits in Palm Beach County and five in
Broward County filed since 1995, according to a review of
local court records by the Sun-Sentinel in March. Here and
elsewhere, allegations against the allied firms include
wrongful deaths, hiring of a psychiatrist stripped of his
license for sexual exploitation of a patient, denying needed
psychiatric medications and ignoring repeated complaints by
patients of serious medical conditions. "They’re legendary in
the legal community for providing second-rate care," says
Robert Saylor, who has sued the local EMSA company a few
times. "They hire the worst doctors."

In his latest case against them,
Saylor won a settlement of $450,000 last year on behalf of
Eric Dale. Dale was an inmate who started complaining about
extreme pains in his back, then his legs, over a few months
until he was virtually paralyzed. The EMSA doctors and staff
wrote in his chart that he was just malingering despite his
pleas for help. Eventually, when he could barely move, they
finally arranged for an MRI at Jackson Memorial Hospital,
which found a tumor on his spine.

For parents, it’s particularly
galling that EMSA’s psychiatrists appear to have an unwritten
policy of denying psychiatric medications, especially to
mentally ill patients suspected of being drug abusers. In
February, Broward Circuit Judge Susan Lebow, angered by EMSA’s
policy of holding mentally ill patients for days without their
meds, hauled company officials into the courtroom and
threatened to hold them in contempt of court unless they gave
patients the needed medication. Denying mentally ill addicts
medication is a practice that, Dr. Sanford Kaufman, the former
chief of the dual diagnosis unit at Savannas Hospital in St.
Lucie County, says is "totally absurd" and violates
professional norms. "If you don’t treat both illnesses at the
same time, you’re asking for trouble and could precipitate a
major psychiatric episode," he says.

EMSA’s approach creates hell for
families. One mother recalls, after discovering that her son
was languishing in jail without medication, "I brought his
prescriptions down there myself and I had to argue with them
to accept them." She’s not sure he ever received them, either,
because he continued to disintegrate while in jail,
occasionally being placed in restraints after violent
confrontations with guards. At one point, her son later told
her, when he began proclaiming that he was the son of God, a
guard amused himself by telling him, "You think you’re the son
of God? Well, go hit yourself." A few guards then roughed him
up, he claims. But since he is mentally ill and his mother has
little in the way of proof, who is going to believe them?

Carhart clearly doubts such
claims. "Both Sheriff [Edward] Bieluch and Col. [George]
Ottmer [the jail supervisor] will not tolerate any
inappropriate behavior by their law enforcement officers in
that division, and if there is any, we will fully investigate
it," she says. "We hold deputies to the highest standards of
professional conduct." She invites any families or inmates
concerned about treatment to complain directly to Ottmer or
his staff.

While the brutality issue is open
to dispute, there’s little doubt that EMSA officials have a
unique perspective on medication denial and other allegations
about substandard jail health care. Linda O’Rourke, the mental
health administrator for EMSA at the Palm Beach jail, said in
a written statement, "Medication may be provided when
clinically indicated." In an interview with City Link, she
denied NAMI members’ charges that medical staff regularly
deprived patients of psychiatric medications. "The patient has
to agree to take the medications," she says. "It’s a
compliance issue: The mom might want them to, but Johnny might
not want to." Yet in her written statement, the company’s
underlying skepticism about using prescribed meds with dual
diagnosis patients is apparent: "Medication-seeking is a
serious problem with this population." In other words,
mentally ill addicts seemingly should go cold turkey on all
drugs.

Despite their unorthodox approach
to using psychiatric medication and the flood of lawsuits,
corporate representatives contend that their health services
have been unfairly maligned. "Any system that depends on
humans to deliver care is going to have some mistakes made,"
says Jean Byasse, the chief legal officer of Prison Health
Services, EMSA’s affiliate. "It’s a difficult population to
deliver health care to. We’re doing better at it than anyone
in the industry." She notes that 74 percent of the cases
brought against them are summarily dismissed, and there’s only
been a "small percentage" of damage recoveries. The real cause
of all the litigation, she argues, is usually the inmates:
"This population has a familiarity with the judicial system,
has time on their hands and can file pro se [without a lawyer]
cases."

Business is booming for the
cost-cutting firm, now in more than 400 jails and prisons, but
at least one Florida county, Pinellas, did not renew EMSA’s
contract in 1997 after an inmate died under the company’s
care. Pinellas Sheriff’s Deputy Cal Dennie said earlier this
year, "We had several jail deaths out there that came into
question, and we had complaints about the care [so] that the
sheriff decided to go on his own." The Palm Beach County and
Broward Sheriff’s offices, though, are sticking by the
controversial company.

But if the criminal justice
system — from cops on the street to jail officials — fails to
recognize and handle mental illness properly, the results can
be tragic. In the past two years, there have been a spate of
fatal shootings of the mentally ill as well as at least one
murder spree, by a troubled 19-year-old who killed two people
and then committed suicide. "The major gap is prevention,"
Judge Leifman says. "We wait until a crisis to attach someone
to services and then it is often too late." On top of that,
the courts and jails are ill-equipped to handle mentally ill
people. "We’ve criminalized mental illness," Leifman contends.
Statewide, there are at least twice as many mentally ill
people in county jails as there are in the state’s mental
health institutions. All told, of the state’s estimated
252,000 adults with severe and persistent mental illness, 80
percent of them get no treatment of any kind, DCF
reports.

And without adequate treatment —
including aggressive followup care — a few of the most
psychotic can get shot or murder others. Some highlights from
Miami:

• In late August, a 22-year-old
discharged Navy man, Delvin Williams, had a psychotic episode
and was shot by police after threatening officers and
civilians in a supermarket parking lot. He’s now in critical
condition at Jackson Memorial Hospital. He didn’t follow up on
the mental health care suggested to him after he ended his
treatment at a Navy medical center in March 2000. If he’d been
plugged into an effective ACT team when he returned to Miami —
assuming any exist — he might not be hovering near death
today.

• In June, a dozen Miami police
officers tried to subdue a knife-wielding schizophrenic and
Army veteran, Richard Beatty, who was slowly wandering along a
city avenue. When they surrounded him, demanding that he drop
his knife and spraying him with mace, he lunged at Officer
Hector Mendez, who fatally shot him 12 times. He had a long
history of living on the streets, going on and off his
medications and misdemeanor offenses. An investigation into
the incident still is under way.

• Last December, John Eric
Carter, 19, went on a rampage in four separate shootings from
Miami to Kendall. He had a long record of crimes, including
possession of a firearm, and was under house arrest for
violating his probation. He’d been examined by psychiatrists
who found him stable but not currently suicidal, went to
counseling and visited his probation officer nearly 60 times.
No one expected him to become a murderer. Yet on Dec. 26, he
killed the father of his ex-girlfriend, the Rev. Keith
Blakely, and a former friend, Jonathan Scarboto Lott; opened
fire on two officers at the county jail; and eight hours
later, shot himself in the head. The surviving families have
met with Judge Leifman to urge reforms in the way judges
decide to place the mentally ill.

In addition, suicidal inmates
sometimes kill themselves in jail. The latest apparent suicide
— still officially unconfirmed — occurred last week when John
Beraglia, 41, beat his head against the wall of his cell in
the North Broward Detention Center after he was placed on a
suicide watch just two hours earlier.

Almost all of these deaths might
have been avoided if patients or inmates had access to decent
care.

There are several key reforms
that could reclaim and literally save the lives of the
mentally ill, but even the most obvious ones — such as
training cops to handle the mentally ill — aren’t being
adopted quickly enough. Still, there are signs of progress.
Working from an approach developed by Memphis police, Miami
Beach police have developed Crisis Intervention Teams (CIT)
composed of specially trained patrol officers who are
dispatched to defuse crisis situations with the mentally ill
and avoid violence. Miami-Dade, Fort Lauderdale and Palm Beach
County police are planning to start learning the techniques
soon. Palm Beach County, though, hasn’t yet developed a
system, as in Broward or Miami-Dade, to refer mentally ill
misdemeanor defendants to treatment facilities. (Mentally ill
felons need a secure treatment facility, too, but they’re not
getting it in South Florida.)

Improved community treatment, if
it ever happens, likely will come as the result of pressure
from groups such as Partners in Crisis, a statewide coalition
of criminal justice and mental health leaders seeking to
prevent the jails and prisons from being swamped with so many
mentally ill people.

But even court-based referrals
and monitoring can’t guarantee that community facilities will
deliver on the services they promise as long as DCF oversight
remains so toothless — regardless of all the paperwork the
department generates. Says Florida NAMI president Faye
Barnette, "They’re falling short on measuring the mental
health providers. Too often, patients are not functioning well
enough." One way to improve performance: Use in-depth
confidential interviewing of patients and families to
determine if clinics are actually helping those they profess
to serve — and hold the clinic leadership accountable if they
fail to do so.

The usual reformist cry is for
more funding, but unless it’s money carefully spent, we’re
likely to see more Ronny Morgans, John Eric Carters and
Christopher Kanes killing themselves or others. One possible
model for change lies in a new plan for the 18-county area in
North-Central Florida being served by a state mental hospital,
G. Pierce Wood, that’s scheduled to close in April. In its
place, with $29 million earmarked by the state Legislature,
will be expanded crisis units, modern medications, short-term
nurse-assisted housing and other programs designed to break
the revolving door cycle that now plagues most of the state,
especially South Florida.

It could take nearly $75 million
to upgrade the rest of the state’s mental health and drug
treatment programs, according to Partners in Crisis. But given
Florida’s Third World-country approach to social spending,
we’ll probably end up with more horror shows like the
ninth-floor of the Miami-Dade County Jail, where the most
violent mentally ill felons are housed. Judge Leifman, a
buoyant man gripped by a reformer’s zeal, takes visitors there
to show the endgame of a system that’s failed. "We’ve
reinstitutionalized the mentally ill here," he says, guiding a
reporter past a faded blue door to a narrow floor with 21
cells, most with two people inside.

On one side, mostly black and
Hispanic men are naked, stripped to prevent suicide and
cloaked only in a synthetic blue blanket that can’t be torn.
Some are speaking incoherently, a few rock themselves back and
forth, while others simply glare at the visitors and guards.
Most have refused to take their medication. With lights on 24
hours, they get their fitful sleep on metal beds without
sheets or blankets, and for a few, there are no beds at all,
just a floor underneath. Outside their ancient, rusting cells
are posted warnings about their crimes or jailhouse
infractions: murder, aggravated assault, "Use Caution, Officer
Assaulter." One violent suspect, a heavyset black man covered
in the blue blanket, begins to shout over and over, his face
pressed against the bars, "You can’t fool with my voodoo
power!"

"You wouldn’t let your dog stay
here," Leifman says. Before he leaves, he takes a final glance
back at the cells and tells the guards, "I don’t know who’s
crazier: the people doing [mental health] policy or these poor
folks."